If physician practices are not currently hard at work creating a strategy for the future, focusing on service expansion, technology, and affiliations, they should get started. Pronto!
Physicians have traditionally expanded their service offerings through ancillaries that function with the oversight—but not the presence—of the physician. Despite ongoing federal interventions discouraging service expansion, physicians have developed ancillary services such as laboratories; imaging; pharmacies; durable medical equipment and nutriceutical offerings; ambulatory surgery centers; and services provided by social workers, nutritionists, physician assistants, and advanced practice nurses, to name a few.
Physicians, as well as hospitals and franchise owners, have experienced mixed success adding Urgent Care Centers to their menus, but the time has come for physicians in particular to revisit the concept. This is due to the recently revised and released Accountable Care Organization (ACO) regulations. The final regulations are much more physician-friendly, making it possible and probable for physicians to lead, own, or participate in an ACO. Based on the goals of ACOs to deliver higher-quality care at a lower price, physician practices should consider positioning themselves as attractive partners to hospitals or other ACO owners. Regardless of whether the practice chooses to participate in an ACO, it’s a good to have as many offers to dance, as is possible.
One quality of an attractive ACO partner in the new paradigm of gain sharing is the ability to provide a continuum of primary care, wellness education, and support that keeps patients out of the emergency room and/or hospital for all but the most appropriate situations (that is, true “limb or life-threatening” situations). The Urgent Care model has the potential to provide an alternative to the emergency department (ED) because all but the most acute illnesses or injuries can be handled in an Urgent Care setting.
Patients Prefer Urgent Care to the ED
There is controversy over the claim that EDs are overcrowded based on uninsured and Medicaid patients’ inappropriate use of the resource. A Kaiser Health News/Washington Post article recently noted, “States are focusing on Medicaid recipients in part because these patients use ERs three times as much as people with private insurance and twice as much as people with no health insurance, according to federal researchers.”
When patients are insured—especially when they are paying a large co-pay at the ED, or have a high-deductible health plan (i.e. they are paying out of pocket for the first $1,000 to $10,000 dollars spent on health care in a plan year)—they are much less likely to seek care in the ED. The research firm Rand found last year that approximately 17 percent of visits to EDs were unnecessary, which added $4.4 billion in annual health care costs. A 2010 study in Health Affairs found that up to 27 percent of all emergency room visits could take place at urgent-care centers or retail health clinics.
Insurers are redirecting patients away from ERs by educating beneficiaries about their after-hours options. Wellpoint, Inc., the largest health plan company in the Blue Cross and Blue Shield Association and the largest U. S. health insurer based on enrollment, is getting creative by offering patients in Calif., Colo., Conn., Ga., Ind., Ky., Maine, Nev., N.H., N.Y., Ohio, Wis., and some parts of Miss. and Va. nearby alternatives to the emergency room via Google Maps. Patients can locate providers approved by their health plan near their home address, or any address where they or a family member (think college kids) happen to be.
Physicians Can Fill the Urgent Care Gap
The Urgent Care Association of America reports that of Americans who do have a regular physician, “only 57 percent of Americans report having access to same or next‐day appointments with that physician and 63 percent report difficulty getting access to care on nights, weekends or holidays without going to the emergency room. Twenty percent of adults waited six days or more to see a doctor when they were sick in 2010.”
We glean from this statement that patients may know the appropriate use of the ED, but must use it when other means of getting care are not available. Practices can step into this gap and make urgent care a part of their service to position themselves as attractive to ACOs, as well as to achieve other goals:
- Make service convenient for their patients so they do not need to resort to the ED, which is unnecessarily expensive and may block other patients from emergency care.
- Meet the needs of working families that have difficulty attending appointments during working hours and appreciate a practice that has its own urgent care.
- Capture income that they are currently losing to retail clinics or other urgent care centers.
- Improve quality of life for physicians due to reduced after-hours patient calls when urgent care services are available.
- Drive down the fixed-cost expense (such as rent/mortgage, utilities, insurance and equipment) per patient, if the Urgent Care co-exists in the practice space.
- Make it easy for young adult patients to establish care with a medical home and become acquainted with wellness principles.
- Improve the quality and consistency of care for patients through immediate access to the medical record, if the urgent care and the record are located in the same site, or if an electronic medical record (EMR) is in use.
- Recent studies have found that the average cost of an urgent care visit is slightly below the average primary care visit: $155 vs. $165. This can be seen as a real win-win for the model that is trying to reduce the cost of health care for the benefit of all stakeholders
- It is not unusual for Urgent Care Centers to augment their walk-in services by providing occupational medicine services, travel medicine services, and sports and school physicals.
Many stakeholders are questioning what the advent of insurance for all Americans in 2014 will mean for those who have not had access to a medical home and coordinated care. The primary care physician is the de facto center of the ACO model, and the hub of care coordination. The influx of patients being encouraged (and hopefully wanting) to abandon the ED for a practice with expanded hours may overwhelm primary caregivers who do not have the potential to provide care seven days per week.
Challenges of Urgent Care
There are barriers to Urgent Care Centers that practices may need to seek advice or assistance to overcome:
- For many patients, going to the ED is a community norm, and one that may be difficult to redirect. The marketing budget for the Urgent Care may need to be significant to overcome long-standing community routines and to educate patients about the new Urgent Care.
- Practices operating as Urgent Cares at the same location will have to communicate with all contracted payers to see what their rules on Urgent Care Centers are, and may need to renegotiate the contract before opening the Urgent Care.
- For the practice operating Urgent Care hours at the same location as non-urgent care services, patients may find it frustrating to understand when the practice is a practice and when it is an urgent care. Patients may also resent that an appointment at 4:30 p.m. has a co-pay of $25 and walking in for service at 5:00 may require a $50 co-pay.
- Urgent Care Centers are not the appropriate venue for all medical problems. Patients who have recently been in auto accidents or have chronic back pain should establish with a medical home. Because of the nature of the Urgent Care setting, it is not unusual for drug-seekers to walk in: Front desk staff needs to be savvy about patient screening. Staff also needs to be at the ready to call 911 if a patient presents with chest pain or shortness of breath.
Other models of care that practices should contemplate, as adjuncts to face-to-face care, are a robust nurse triage program, telemedicine, and virtual visits.
Statistics on Urgent Care in America
Courtesy of Urgent Care Association of America’s “Urgent Care Industry Information Kit, 2011” (www.ucaoa.org):
Number of Urgent Care Centers in the U.S. – 8,700
Number of visits per center per week – 342
Ownership – 50 percent physicians/physician group, 13.5 percent corporation, 7.7 percent hospital
Comparative Visit Fees – Urgent Care Center $156, Primary Care Physician Clinic $166, Emergency Room $414
UCAOA provides educational programs, the monthly Journal of Urgent Care Medicine (www.jucm.com), and a variety of different resources for starting a new urgent care center, providing clinical care in the urgent care setting, and running a successful urgent care practice.
References:
Kaiser Health News “As Hospitals Push ERs, States’ Medicaid Budgets Pressured” By Phil Galewitz, KHN Staff Writer, Aug 22, 2011
Health Affairs September 2010 vol. 29 no. 9 1630-1636 “Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics” by Robin M. Weinicki, Rachel M. Burns, and Ateey Mehrotra
Health Affairs September 2010 vol. 29 no. 9 1630-1636 “Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics” by Robin M. Weinicki, Rachel M. Burns, and Ateey Mehrotra
